Improving Surgical Recovery with a Team Approach
Patient ambulation after surgery is a key factor in the Enhanced Recovery After Surgery protocols being implemented throughout Stanford Hospital to improve recovery and reduce length of stay. Shown here is Physical Therapist Liz Stark, PT (left) guiding a surgical patient around the nurse's station.
In the last year, the High Value Care Team in the Department of Quality has embarked on efforts with various multidisciplinary teams throughout the hospital, working to optimize patients’ recovery from surgery and reduce length of stay. These Enhanced Recovery After Surgery (ERAS) teams are made up of surgeons, anesthesiologists, nurses, advanced practice providers (APPs), physical therapists and dieticians, who worked together to create and carry out detailed, standardized care pathways for patients undergoing colorectal, pancreatic resection, gyn-onc, neuro/spine and esophageal surgeries.
ERAS protocols start when a patient is first identified for surgery. That initial appointment triggers a cascade of perioperative events, from pre-op to intra-op to post-op, for both inpatient and outpatient surgeries. The evidence-based pathway has specific goals at each step that ensures patients receive standardized care that follows best practices. ERAS protocols are designed to reduce the variability in care that can affect quality of care and length of stay.
“The goal is to develop pathways for the patient’s perioperative journey to reduce their surgical stress response, optimize their physiologic function and facilitate their recovery,” said Amy Lu, MD, anesthesiology lead for ERAS. “ERAS is patient-centered, consensus and evidence-based, integrated and multidisciplinary. It’s the right approach for patient care and improves the patient experience.”
Creating ERAS pathways and ensuring that they are followed requires a team approach, said Lisa Cianfichi, NP, Manager of the Anesthesia Preoperative Evaluation Clinic. At these preoperative appointments, Cianfichi, along with other APPs from both the surgery and preoperative anesthesia clinics make sure that patients are medically optimized for surgery by reviewing their medications and co-morbidities. This appointment helps the team identify patients with chronic pain or nutrition issues and can set into motion follow-up pain or dietary consults during the patient’s post-op hospitalization.
“ERAS truly provides coordinated care,” said Cianfichi. “We all work for that one person, the patient, and it is a team sport.” During the pre-operative clinic visit, the APP outlines the expected recovery path for each patient—What should patients expect after surgery? When will they be up and out of bed? When will they be expected to walk? Will they be discharged to home? What medications or home health equipment will they need? What follow-up appointments will be scheduled?
On the day of surgery, anesthesiologists utilize evidence-based analgesic and anesthetic regimens, using multi-modal anesthesia when applicable such as minimizing the use of opioids and using analgesic adjuncts. Special attention is also given to reducing post-op nausea and vomiting and reducing other barriers to recovery. These practices optimize the surgical experience, and were being employed even before ERAS implementation.
According to an article in the March 2017 issue of JAMA Surgery, “Enhanced Recovery After Surgery is an evidence-based care improvement process for surgical patients. Implementation of ERAS programs results in major improvements in clinical outcomes and cost, making ERAS an important example of value-based care applied to surgery.”
At Stanford, these coordinated efforts are paying off, said Lu. High value care teams in colorectal, pancreatic, spine and gyn-onc surgery have begun to reduce variability of care and reduce length of stay.